Introduction
Childbirth is the most common reason for hospitalization in the United States. While adequate pain control after birth is critical for a healthy recovery, opioid use has risks. Clinical practice guidelines for acute pain reduce opioid prescribing without compromising analgesia. However, existing guidelines for postpartum pain management have key limitations. We aim to collect and synthesize recent literature surrounding pain management following birth, higher-order perineal trauma, and peripartum tubal ligation to support the development of new clinical practice guidelines for postpartum pain management.
Methods
We conducted a systematic review and narrative synthesis of studies addressing postpartum pain management (opioid medications, non-opioid medications, and nonpharmacologic methods). Studies assessed opioid use, analgesia effects, patient-centered outcomes, and disparities in the general population, patients with opioid use disorder (OUD), chronic pain, and psychiatric conditions. Ovid MEDLINE, Elsevier's Scopus, Elsevier’s Embase, Google Scholar, PubMed, and Web of Science were searched to identify relevant articles. Articles were screened and abstracted by two researchers. Quality was assessed using the RAND/UCLA Appropriateness Methodology approach.
Results
Of 2,255 studies screened, 69 were included: 1 high-quality (clinical practice guideline); 22 moderate-quality (RCTs); and 46 low-quality (non-RCTs, observational studies). A heterogenous group of studies reported that multimodal, non-opioid interventions (e.g., scheduled ibuprofen and acetaminophen) reduced opioid use after vaginal and cesarean birth without increasing pain. Nonpharmacologic studies were limited, with low evidence for analgesia but high satisfaction postpartum. Tailored prescribing reduced outpatient opioid use without worsening pain after cesarean birth with limited evidence following vaginal birth. Discharge prescribing studies showed variability, overprescribing, and racial/ethnic disparities following vaginal and cesarean birth. Patients with chronic pain and psychiatric conditions had increased opioid exposure and persistent use following vaginal and cesarean birth. Higher-order perineal trauma and tubal ligation were associated with increased opioid use after discharge. Patients with chronic pain and psychiatric conditions had increased opioid exposure and persistent use.
Conclusions
Multimodal oral opioid-sparing strategies provide adequate pain control while limiting opioid use after vaginal birth. Non-pharmacologic methods may provide low-risk enhancement in pain management. There are significant evidence gaps for postpartum pain management in patients with OUD, chronic pain, and psychiatric conditions.